"Signature Authorization Letter" - Nebraska

Signature Authorization Letter is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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PRINT FORM ON LETTERHEAD
DEPARTMENT OF MOTOR VEHICLES
DATE:
FINANCIAL RESPONSIBILITY DIVISION
PO BOX 94877
LINCOLN NE 68509 4877
SIGNATURE AUTHORIZATION LETTER
This signature authorization letter will replace any prior letters on file with the Nebraska Department of Motor
Vehicles.
1. List of insurance companies that you submit Nebraska SR filings for (if more than five, you will need
to attach another page with information on it):
NAIC NUMBER
COMPANY NAME
2. Signature on filings will be as follows – check applicable:
Hand signed
Ink stamped
Pre-printed
3. SR filing type:
Standard (3 x 5 pink/yellow filing)
Custom - you must submit a
blank
sample of both the SR22 and SR26 filing (please do not
include any ID information for your insured on the sample)
4. Does your company allow agents to submit SR filings – select applicable:
Yes (If yes – filing must contain agent return address stamp, cannot be back dated and must
follow all applicable rules for your company)
No
Special Instructions (i.e. if you don’t allow your agents to submit filings - do you require the
filings to come from a specific office, etc.):
PRINT FORM ON LETTERHEAD
DEPARTMENT OF MOTOR VEHICLES
DATE:
FINANCIAL RESPONSIBILITY DIVISION
PO BOX 94877
LINCOLN NE 68509 4877
SIGNATURE AUTHORIZATION LETTER
This signature authorization letter will replace any prior letters on file with the Nebraska Department of Motor
Vehicles.
1. List of insurance companies that you submit Nebraska SR filings for (if more than five, you will need
to attach another page with information on it):
NAIC NUMBER
COMPANY NAME
2. Signature on filings will be as follows – check applicable:
Hand signed
Ink stamped
Pre-printed
3. SR filing type:
Standard (3 x 5 pink/yellow filing)
Custom - you must submit a
blank
sample of both the SR22 and SR26 filing (please do not
include any ID information for your insured on the sample)
4. Does your company allow agents to submit SR filings – select applicable:
Yes (If yes – filing must contain agent return address stamp, cannot be back dated and must
follow all applicable rules for your company)
No
Special Instructions (i.e. if you don’t allow your agents to submit filings - do you require the
filings to come from a specific office, etc.):
5. If you allow your agents to submit filings – does the home office also send the exact same filing:
Yes
No
Not applicable – agents aren’t authorized to file
6. Current Policy Number format (we can build edits in our system for 3 different policy number
formats per company). Please define your policy number format in the applicable fields below using
the following characters: # = numeric digit, $ = numeric digit or a blank space, & = alpha character, *
= alpha character or a blank space, ? = either a numeric digit or alpha character. See examples
provided below:
Show your actual policy number
Format using characters listed above
8-10 numeric characters in length:
########$$
01234567 or 0123456789
2 alpha characters and 4 numeric:
&&####
AA1234
3 specific alpha character and 3 numeric:
ABC###
ABC123
POLICY NUMBER FORMAT
TYPE OF POLICY
Show your actual policy number
Format using characters listed above
Personal lines:
Small fleet lines:
Commercial lines:
Other:
Special directions to the Department of Motor Vehicles concerning the policy number (i.e. omit the
suffix, omit prefix, etc.):
7. Because of the Federal Privacy Law, you will need to designate Support Contact(s) for your company
(name, phone number, email address). This list will be the only people we would contact when we
have issues with the SR22 filing that requires use of protected information:
CONTACT NAME
DIRECT PHONE NUMBER
EMAIL ADDRESS
8. Can the name/phone number of your designated contact(s) be released to the agent or insured if we
are asked for it – please select applicable:
Yes
No
If not, who can we have the agent or insured contact for assistance (name, phone number, email
address):
CONTACT NAME
DIRECT PHONE NUMBER
EMAIL ADDRESS
9. The Nebraska Department of Motor Vehicles has designated the contacts below for SR issues that
require use of protected information (the names/numbers/email addresses below
ARE NOT TO BE
RELEASED
TO ANYONE OTHER THAN YOUR DESIGNATED CONTACTS):
CONTACT NAME
DIRECT PHONE NUMBER
EMAIL ADDRESS
Lisa Wolfe
402-471-6357
lisa.wolfe@nebraska.gov
Joan Johnson
402-471-3985
joan.johnson@nebraska.gov
Kathy VanBrocklin
402-471-3901
kathy.vanbrocklin@nebraska.gov
10. Who should the Department of Motor Vehicles contact if there are issues regarding an agent or
agency (name/phone number/email address):
CONTACT NAME
DIRECT PHONE NUMBER
EMAIL ADDRESS
11. Do you allow SR filings in Nebraska for drivers that live in another state (if you do, the filing must be
submitted from your home office – we will not accept agent issued filings for out-of-state drivers) -
select applicable:
Yes
No
12. If we need to return a filing for any reason, who would it be sent to (name/complete mailing
address):
CONTACT NAME
STREET ADDRESS
CITY/STATE/ZIP CODE
13. List of all personnel authorized to sign filings (please try and limit to no more than five):
PRINTED NAME
SIGNATURE AS IT WOULD APPEAR ON THE FILING
14. Name of person submitting authorization letter:
Printed name:
Signature:
Title of position with company:
Phone number:
Email address:
Please contact Lisa Wolfe at
lisa.wolfe@nebraska.gov
for any questions concerning
completion of this authorization letter.
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